Tuesday, June 28, 2011

Lots of comments on the previous post-- the most recent one (June 28/12:57) seems to have it right. Yes, you should be able to get your records. Yes, ethically suspect. But likely not actionable. Doesn't help if the patient is told to follow up in three months and never does, doesn't see any doctor for years, no one else ever has a chance to look at the chart.

* * *

Moving on... residency tip #374... one of my interns, talking to the attending:

"Yeah, I'm definitely not looking forward to my next rotation, I hate working with all of those douchebag attendings."

"Which attendings do you mean?"

"Oh, you know, Dr. [Smith] is a huge douchebag."

"Dr. Smith is one of my closest friends."

* * *

"I never used to have heart failure," said the patient.

"Yeah, it starts to happen to people around your age, unfortunately."

"No, you don't understand, I never had a problem with my heart."

"Yeah, I know."

"So I don't understand. I never had a problem."

"Yeah, these things happen over time."

"But nothing happened to cause it. So I don't know where it came from."

"Yeah, these things happen, lifestyle factors, genetics, over time things happen to everyone."

"Well, I never used to have it until I got that echocardiogram. I think that caused it."

"The echo diagnosed it, it didn't cause it."

"Yeah, I don't know about that."

"People aren't born with heart failure. These things happen. It doesn't help that you're 150 pounds overweight, sedentary, high blood pressure, diabetes. We can put you on medication, but there are also lifestyle changes you can make."

Sunday, June 26, 2011

"Do me a favor and take me a quick look at this," I asked my co-resident. "This is a positive finding on the echo, right? He should have totally been medicated, there should have been follow-up..."

"Sure, yeah. Definitely."

"Except now it's two years later, the patient is back, complaining of chest pain... and I look at the notes... he was told two years ago that he was fine, the echo came back negative. So there was no treatment, no follow-up."

"What?"

"I don't know if the doctor was looking at the wrong chart..."

"And you're sure the echo lines up..."

"Either the echo was labeled wrong, and so it's someone else's report I'm looking at, or whoever saw him two years ago looked at the wrong report and told him he was fine when he wasn't."

"Either way... there's a patient in there now who has chest pain and probably had a positive echo two years ago and nothing's been treated."

"Yep."

"That's not good."

"Nope."

This post is brought to you by the Association to Please Ask For A Copy Of Your Test Results, and the Committee to Double-Check Your Doctor.

Friday, June 24, 2011

"No, I don't think I'm being unduly influenced by free trips from pharmaceutical companies," said my attending. "And let me show you some pictures of my children, Angeliq, Portia, and Allegra."

"And of course my dogs, Yasmin and Lyrica."

I want to get a fish and name him Zithromax. Maybe a goldfish. One of those little guys, who lasts about five days before he dies and has to be flushed down the toilet.

I guess I understand why someone might name a pet after a drug-- some of the names are quite mellifluous (Boniva, Cymbalta, Dovonex)-- but a child? I feel like it's a mark of a seriously limited life that someone must lead to think that Flonase sounds like the perfect name to saddle a child with.

I wonder if they hire doctors to name these things. It seems like a far more civilized job than what we actually do. I want to sit in a room all day and come up with names like Requip and Symbicort.

If anyone names her baby Uniretic or Valtrex, I'm reporting them to the psych department.

"Excuse me, doctor. I just wanted to know if you think it would make sense for me to schedule my mother's funeral for next Tuesday. You know, I want to order some food, have to tell the relatives. I just wanted to get a sense of the timeline."

"Um, your mother's still alive."

"Oh, I know, but she's clearly declining."

"She's obviously not in great shape, but she's still alive."

"She's 95, she's going downhill very quickly."

"She's stable right now. There is nothing that is actively killing her. I can't tell you how much longer she's going to live, but I see no reason to think we're looking at hours or days right now."

"She has no mental function."

"We just had a lovely conversation. She's in terrific spirits. She has the mental status of a demented person. Her responses make sense, she's comprehending what people are saying."

"She doesn't even look at me."

"She looks at everyone else. I think she is choosing not to look at you."

"That's ridiculous."

"You're trying to plan her funeral while she's still alive. I feel like perhaps she's not that excited to try and rouse herself to have a conversation with you."

"She doesn't even know where she is."

"She just paged the nurse and asked for more water."

"It was a reflex. She's dying."

"She's 95 years old, she had a stroke, she's not in great shape. But she's comfortable, she's stable, she's smiling-- this is not someone who seems to imminently be dying. I see dying people every day here. She is not a patient I have reason to be highly concerned about right now, as far as whether she will make it until tomorrow."

"But I need to know when to tell everyone the funeral is."

"I think you need to take a step back and stop worrying about the funeral until your mother actually passes away."

"But I want to know if there's anything we can do to make a clearer timeline. I've missed a number of days of work for this."

"Again, she's still alive. I'm sorry you've had to miss work. I don't have another answer for you. We're not going to kill her for your convenience."

"I'm not asking you to kill her. I just wonder if there's a way to end her suffering peacefully, on a schedule."

"Sir, she doesn't seem to be suffering. She's smiling, she's eating."

"She's not eating much."

"She's 95 years old, and in a hospital bed. She doesn't need that much food."

"There's nothing you can do?"

"There's nothing we're trying to do. She's stable right now. The natural course of things will happen, at their own pace. I can't tell you if she has days, or weeks, or months."

"She doesn't have months."

"There's no evidence to support that."

"Look at her. Put her out of her misery."

"She's laughing. She and the nurse are laughing. She seems to be doing okay, fortunately. You should spend some time with her."

Thursday, June 16, 2011

The economics of home health aides.

I have a question, and it's not really a medical one. Or even any of my business. But, just curious, what's the right reaction here, if there even is one. Patient who's dying, has a 24-hour home aide living with her. I've spent some time with the very-involved (and somewhat difficult) daughter and son-in-law. They happened to mention to me that once their mother dies, they want to let the aide continue to live in the mother's house, rent-free, in exchange for helping them out, coming over to clean their house, shop for their food, and be there "in reserve" in case one of them needs an aide down the line.

The aide, in a separate conversation, mentioned to me that she's very grateful that the family cares about her, but she wishes she had more opportunities so she wouldn't have to necessarily go along with this plan just because she needs a place to live.

I know this is all none of my business. And I also know that in a free market economy, people make choices and who am I to judge those choices.

But does this not sound a little like indentured servitude?

I think it's the personal services piece of it that I find myself wondering about. If they were letting her live rent-free or for a low rent, and both parties are happy, great. But to let her live rent-free in exchange for some bundle of responsibilities, without paying her-- and using the fact that she has limited economic resources to perhaps take advantage-- makes me uncomfortable with their arrangement.

At the same time, the value of a rent-free apartment is something significant, and if the work required is fairly minimal, what's wrong with that? This is a fair economic exchange, if both sides agree and no one is actually being forced to make that choice, no? The rental value is equivalent to salary. So why do I have the reaction I have?

Wednesday, June 15, 2011

Trying to transfer a patient to a hospice facility. The social worker comes back and says, "they will only take her if you can guarantee she will die within the next 60 days."

And how would you like me to do that?

Talked to the attending, he told me to guarantee it, what's the difference. Not like they're going to smother her if she's still alive in two months. Unless they do. Or they try and give her back.

As if the hospice facility should really get to be so selective. This isn't med school admissions we're talking about. Oh, we only want the best hospice patients, the ones least likely to tie up our beds for so long. Not sure what the Medicaid reimbursement looks like, maybe they get more up front and so it's more economical to have lots of turnover? I assume that's what's going on, otherwise I have no idea why they would care. Someone have a reservation for August? Gonna be dying in a couple months and want to stake out a bed in advance?

So we sent her over there, where she's sure to get amazing care, since the incentives are so very well aligned... argh.

Monday, June 6, 2011

Spent the day in clinic. "You're the neurologist, right?" asked one of my patients.

"No, this is the general medicine clinic."

"I'm supposed to see the neurologist."

"You have an appointment for general medicine."

"That's a mistake."

"Well, maybe I can help you, or at least help you make an appointment to see the neurologist."

"I saw a doctor last time, he said to come back and see the neurologist. So I came back."

"He must have meant you should make an appointment at the neurology clinic."

"That's not what he said. He said come back here, and see a neurologist. So I am back here, and I want to see a neurologist."

"There are no neurologists here. They assigned you to me. But I'm not sure I will be able to tell you anything different than what the other doctor told you. Do you mind waiting here while I make a call and see if they can squeeze you in at the neurology clinic?"

"I do not want to wait any longer. I have been here for two hours."

"I'm sorry you were waiting here for two hours. But let me see what I can do."

"I thought you said you are not a neurologist."

"I'm not. But I'm trying to help you. I'm going to call the neurology clinic."

"I thought I had an appointment with a neurologist."

"You didn't. But I'm going to try and get you one. Just wait here."

"No."

"Why not?"

"Because I don't want to wait any longer."

"I can only help you if you wait a few more minutes so I can call the other clinic."

Thursday, June 2, 2011

The elderly get a raw deal in the hospital. You could be the most high-functioning 95-year-old on the planet, living on your own, no signs of dementia, coming into the ER for an entirely treatable and non-serious reason-- a broken toe, let's say-- and as soon as anyone looks at your chart and sees that you're 95, you are going to be basically disregarded and assumed to be 24 hours from death. It becomes almost like a game of telephone, from the resident who takes the history, to the next doctor who sees you, to the next, to the next, each time making you out to be less like a functioning person and more like a corpse.

"So, we have a 95-year-old, broken toe. Came in on her own, lives independently, I don't think we need to admit her."

"I'll just write down failure to thrive," said the attending. "And we'll keep her overnight for observation."

"She's thriving fine. I don't think we need to admit her-- she's probably in better shape outside than in here, she can pick up who knows what."

"Yeah, but just in case."

"Just in case what?"

"She's 95."

***

Two hours later, the attending gives his report:

"95 year old, failure to thrive. Came in unable to walk--"

"She has a broken toe."

"Sure, yeah. Incontinent--"

"She spilled water on herself."

"Okay, fine, then we'll say hand tremors, unsteady--"

"No..."

"We admitted her with syncope--"

"She said she was dizzy. It was because she spilled her water and the nurses wouldn't get her any more--"

"Yeah, syncope, agitation--"

"You'd be agitated too if you had to wait 6 hours in the ER with a broken toe."

"We think it's a broken toe. Maybe it's a broken hip."

"It's not a broken hip."

"We're keeping her for observation, we'll get social work involved to help with placement--"

"She lives at home."

"Yeah, well, we should let social work decide if that's okay--"

"She's high-functioning, she's fine--"

"And the plan going forward is, uh... hospice."

"She has a broken toe."

"Yeah, I don't really think we should be bothering to treat it. Let's just say hospice. She signed a DNR, right?"

"She's a functioning woman."

"Let's prep an OR and we can just remove the whole foot so it doesn't give her any more problems."

"What?"

"Yeah, and let's get psych involved to deal with her depression."

"What depression?"

"She reacted very poorly when I said we were going to remove her foot."

"Unfortunately she's not healthy right now. She has leukemia, and she needs a bone marrow transplant. Everyone should eat healthy, of course. But that's not the issue that's most important for your mother right now."

"I've heard people eat bone marrow. Should she be doing that? Will that help?"

"No. It's not about eating bone marrow. We need to replace the bone marrow she has."

"Can we do that with the bone marrow in restaurants?"

"That's not human bone marrow."

"So it wouldn't work?"

"That's correct."

"What if we found human bone marrow."

"Well, that's what we're looking for. We're going to try and find a match for your mother so she can get the transplant."

"And what will you do with her existing bone marrow?"

"We get rid of the old marrow with radiation and chemotherapy and then introduce the new marrow. But that's a very simplified way of describing it, and it's not my specialty."

"Can we keep the old marrow?"

"There's not going to be a physical object to keep."

"So it's not like a liver? We wanted to keep my uncle's liver, but the hospital wouldn't let us."